IAJPS 2017, 4 (10), 3698-3701 Abdul Haque Khan et al ISSN 2349-7750

CODEN [USA]: IAJPBB ISSN: 2349-7750

INDO AMERICAN JOURNAL OF

PHARMACEUTICAL SCIENCES
http://doi.org/10.5281/zenodo.1036536

Available online at: http://www.iajps.com Research Article

EVALUATION OF SUB-CLINICAL HEPATIC ENCEPHALOPATHY BY

PSYCHOMETRIC TESTS
Dr. Abdul Haque Khan 1*, Dr. Muhammad Adnan Bawany 2, Dr. Mukhtiar Hussain Jaffery 1, Dr.
Aida Nasar 2 , Dr. Hamid Nawaz Ali Memon 3, Dr. Abdul Subhan Talpur4 , and Dr. Muhammad
Ayyaz 5 and Dr. Zulfiqar Ali Qutrio Baloch 5
1
Department of Medicine, Liaquat University of Medical and Health Sciences (LUMHS) Jamshoro
2
Isra University Hospital Hyderabad, Sindh, Pakistan
3
Zulekha Hospital Dubai United Arab Emirates
4
Liaquat University Hospital Hydderabad / Jamshoro
5
Brandon Regional Hospital Brandon, Florida, U.S.A
Abstract:
Objective: To evaluate the sub-clinical hepatic encephalopathy by psychometric tests.
Patients and Methods: The cross sectional study of six months was conducted at the tertiary care hospital
Hyderabad. The inclusion criteria were the patients of 12 years of age, either gender, diagnosed to have cirrhosis
of liver by history, clinical examination, laboratory findings, ultrasonography and liver biopsy and spare from the
medications the impaired the cognitive function. A detailed clinical history, physical examination including
neuropsychological tests [NCT and DST] and the baselines and specific relevant investigations were advised and
the data was collected on predesigned proforma. The frequency and percentages was calculated while the numerical
statistics were used to compute mean SD.
Results: Thirty patients with histologically proven cirrhosis were recruited and studied for subclinical hepatic
encephalopathy during six months study period. The mean age SD for whole population was 43.98 7.83 years
with male gender predominance (66.6%) while the mean SD for DST and NCT was 241.825.83 and 152.987.75.
The common etiologies identified were Hepatitis B (40%), hepatitis C (33.3%) and hepatitis B and C (16.6%)
while DST and NCT were shown to be abnormal in 17 (56.6%) and 18 (60%) individuals with chronic liver disease
respectively.
Conclusion: The sub clinical hepatic encephalopathy on the basis of NCT and DST could better predict a
subsequent episode of overt hepatic encephalopathy in chronic liver disease.
Keywords: Sub clinical hepatic encephalopathy, psychometric tests and Hepatic encephalopathy.
Corresponding author:
Dr. Abdul Haque Khan, QR code
Department of Medicine,
Liaquat University of Medical and Health Sciences (LUMHS),
Jamshoro.
Email: zulfikar229@hotmail.com

Please cite this article in press as Abdul Haque Khan et al , Evaluation of Sub-Clinical Hepatic Encephalopathy
by Psychometric Tests, Indo Am. J. P. Sci, 2017; 4(10).

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 IAJPS 2017, 4 (10), 3698-3701 Abdul Haque Khan et al
INTRODUCTION:
Hepatic encephalopathy (HE) a lethal complication
of end stage hepatic disease and considered as
neuropsychological syndrome occurs in patients with
either severe hepatic failure, chronic liver disease or
as a consequence of surgical portal systemic shunts
and traditionally it is graded into four (4) clinical
grades [1-3]. Despite clinical grading of hepatic
encephalopathy a subclinical state is explained in
which individuals with liver cirrhosis regardless
about etiology presents number of
neuropsychological errors but yet have a normal
neurological & mental status on global neurological
physical examination [4-6]. Several physicians advise
by using a combination of 2 to 3 psychometric tests
as diagnostic tool of subclinical hepatic
encephalopathy (SHE). Several others
neurophysiological tests as visual evoked potential
and electro encephalography (EEG) sometimes also
used [7, 8]. However controversies persist whether
these neurophysiological tools are appropriate for
clinical psychometric tests [9, 10]. The sub clinical
hepatic encephalopathy prevalence varies from 40%
to 85% depends on type of tests and sample size
used. Thus, in view routine periodic assessment of
subclinical hepatic encephalopathy is recommended
in individuals with chronic liver disease and the
present study was an attempt to observe the
frequency of subclinical hepatic encephalopathy by
clinical psychometric tests in patients with liver
cirrhosis.
PATIENTS AND METHODS:
The cross sectional study of six months was
conducted at the tertiary care hospital Hyderabad.
The inclusion criteria were the patients of 12 years
of age, either gender, diagnosed to have cirrhosis of
liver by history, clinical examination, laboratory
findings, ultrasonography and liver biopsy and spare
from the medications the impaired the cognitive
function while the exclusion criteria of the study
were patient having overt HE, preexisting psychiatric
& neurological disorders causing cognitive
dysfunction, difficulty in performing psychometric
tests as having visual errors and the patients already
on antipsychotic / antidepressant therapy. The
participants had administration for
neuropsychological test and the non probability
www.iajps.com
ISSN 2349-7750
purposive sampling technique was used to recruit the
patients while the informed consent was taken for
participation after explaining the purpose of the study
to each individual and the patient assured prior to
consent that non participation dont affect the
treatment strategy. A detailed clinical history,
physical examination including neuropsychological
tests [NCT and DST] and the baselines and specific
relevant investigations were advised and the data was
collected on predesigned proforma. The number
connection test (NCT) and digit symbol test (DST)
were used as psychometric tests. The patients were
advised to participate by providing the pencil and
instruct to begin by draw a line at number one in
continuous order until the marked end of circle is
obtained. The time was noted during entire test while
during the procedure if the subject had mistake then
advise to continue the process by making point out
for mistake. The score is expressed in terms of the
time in seconds required for the test. The test was
found to be highly sensitive to brain impairment with
diffuse involvement. Digit symbol test consists of a
paper upon numbers one to nine randomly placed in
04 lines of 25 squares each. The initial 10 squares
were considered as for practice purpose. The time
duration to finish the test considered as score
obtained and the errors were also observed, the
duration of the test takes maximum approximately
seven minutes. In NCT-A, the individuals joined the
numbers in sequence as fast as possible while in
NCT-B, the individuals joined alternatively the
numbers & letters as early as possible. The DST was
measured in points while NCT and DST were
measured as seconds. The data was saved in SPSS to
analyze by evaluating the frequencies, percentages
and mean standard deviations.
RESULTS:
Thirty patients with histologically proven cirrhosis
were recruited and studied for subclinical hepatic
encephalopathy during six months study period. The
mean age SD for whole population was 43.98
7.83 years with male gender predominance (66.6%)
while the mean SD for DST and NCT was
241.825.83 and 152.987.75. The demographical,
clinical profiles and status of psychometric tests of
the patients with subclinical hepatic encephalopathy
are shown in Table 1-2.
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 IAJPS 2017, 4 (10), 3698-3701 Abdul Haque Khan et al ISSN 2349-7750

TABLE 01: THE DEMOGRAPHICAL AND CLINICAL PROFILE OF THE PATIENTS

AGE (years) FREQUENCY (N=30) PERCENTAGE (%)
12-19 02 6.6
20-29 03 10
30-39 07 23.3
40-49 08 26.6
50-59 08 26.6
60+ 02 6.6

GENDER
Female 10 33.3
Male 20 66.6

RESIDENCE
Urban 09 30
Rural 21 70

Cause of chronic liver disease

Hepatitis B 12 40
Hepatitis C 10 33.3
Hepatitis B and C 05 16.6
NAFLD/ NASH 02 6.6
Hepatoma 01 3.3

Child-Pugh class
A 08 26.6
B 17 56.6
C 05 16.6

TABLE 02: THE STATUS OF PSYCHOMETRIC TESTS IN PATIENTS WITH SUB-CLINICAL

HEPATIC ENCEPHALOPATHY
Digit symbol test (DST) Frequency (N=30) Percentage (%)
Normal 13 43.3
Abnormal 17 56.6

Number connection test (NCT)

Normal 12 40
Abnormal 18 60

DISCUSSION: in the study of 179 patients by Groeneweg M, et al

In current study we had performed psychometric tests
study to evaluate the relationship among the detection
of sub clinical hepatic encephalopathy (SHE) and the
development of episodes of hepatic encephalopathy
[11]. The diagnosis of SHE is important in the
context of quality of life or traffic accidents. Still less
well known is either SHE is a predictor for overt
mental changes. If such relation exits than the
association could warrant a search for early
evaluation and possible management of individuals
with SHE [12]. In present study we evaluate the
frequency of SHE in patients of liver cirrhosis
patients by using NCT and SDT. The mean age SD
for whole population in present study was 43.98
7.83 with male gender predominance. The mean age
[13] was 50.002.52 years with 113 males and 66
females, while the range of patients in a study by
Nader was 35-70 years with a mean of 51 years
respectively [14]. In present study the etiology for
liver cirrhosis were chronic viral hepatitis B, C,
hepatoma and NAFLD / NASH while the cause for
liver cirrhosis was viral hepatitis in seventy five
patients, alcoholism in forty individuals & other
etiologies in seventy one subjects in the study by
Groeneweg M [13]. In an another study by Nadar 24
hepatitis C , 14 alcoholic CLD, 2 hepatitis B and two
patient had both viral hepatitis B and C was studied
[14]. In the study by Quero JC, et al [15] 50% of the
studied population had abnormal neuropsychiatric
tests.

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 IAJPS 2017, 4 (10), 3698-3701 Abdul Haque Khan et al
In current series the total abnormal rate of NCT and
DST in chronic liver disease was 60% and 56.6
respectively and supported as a sensitive and specific
tool to detect SHE and it is consistent with the former
literature reported that NCT and DST able to detect
SHE with sensitivity of 76% and a specificity of 96%
respectively [16]. In present study we choice DST
and NCT as both tools are sensitive and have a easy
use and accessibility at bed side especially during a
routine visit of patients with liver cirrhosis [17].
Early evaluation and management of SHE seem
extremely necessary in Pakistan due to huge
population and high incidence of chronic liver
diseases in this country [18]. The raised prevalence of
SHE in cirrhotic subjects should concentrate us to
have attention on these important observations
frequently encountered in our daily medical practice
[19].
CONCLUSION:
The existence of impaired neuropsychological
findings in patients with liver cirrhosis patients is
confirmed by our results through psychometric tests
(NCT and DST). The sub clinical hepatic
encephalopathy on the basis of NCT and DST could
better predict a subsequent episode of overt hepatic
encephalopathy & recommended as substitute of
intelligence quotient (IQ) test for SHE in patients
with liver cirrhosis.
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